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Global Health, Infectious Disease, Patient Care, SMS Unplugged

The hand-sanitizer dilemma: My experiences treating patients in Uganda

The hand-sanitizer dilemma: My experiences treating patients in Uganda

Ugandan hospital - smallSMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

A thick green glob landed on my scrub top at the same time that the first drop of sweat rolled down the small of my back. I tried not to grimace and discretely walked over to the hand-sanitizer dispenser. But like every other hand sanitizer I had tried, this one was empty. Yesterday I had also discovered that the only bathroom in the hospital had no toilet paper. It was 7 AM, and I would be using my pocket toilet-paper stash to clean off sputum from the hacking patient that apparently all the doctors knew to avoid standing in front of. The day was off to a good start.

How, I wondered as we continued rounding, did doctors respond to this dilemma – having to care for patients without being able to fully protect themselves – when they were in health centers treating Ebola. I tried not to think about what I would tell my parents if I developed rare infectious symptoms in a few days. We were in Uganda, countries away from the Ebola outbreak, but there were still plenty of infectious agents we could and probably were exposing ourselves to.

Just as I was wracking my brain for the names of the bacteria and viruses that might be deadly, I noticed one of the doctors rest his hand on a patient’s shoulder. And it dawned on me that the real dilemma was not about what I, who had access to the best medical care, might pick up, but rather about what I might pass from patient to patient.

It’s ironic that in the U.S., patients have to remind doctors to reach out and touch their shoulder or hand at an appropriate time – to make patients feel that the doctor connects with them on a human level. Yet here in Uganda, the  doctors know when to reach out to their patients, they know how to talk to the patient’s family. My clinical-skills professors would love to see this.

But if the hand-sanitizer dispenser was empty for me, it was empty for the  Ugandan doctors as well. We were told as first-year medical students that we would fail our “Practice of Medicine” final if we forgot to sanitize our  hands upon entering our standardized patient’s room. So what were we to do when we had more than twenty patients in one room, each with at least two family members, and no hand sanitizer for anyone? How many of these dozens  of people were walking around with my hacking patient’s sputum on them as  well?

The doctors certainly could be spreading infectious agents. But given the proximity of patients on the wards, those very same infectious agents had likely already been spread between the patients overnight – before we even arrived that morning. I couldn’t help but wonder which was more important to the patients who had a 50 percent chance of survival: to feel that their doctor was treating them as a human being or to increase their chance of survival by a negligible margin? How big or small would the margin introduced by the doctor’s touch have to be to tip the scale one way or another?

Before I could finish thinking through my ethical dilemma, we left the ward to scrub in for surgery. There I found the only working hand-sanitizer dispenser.

Natalia Birgisson is a second-year student at Stanford’s medical school. She is half Icelandic, half Venezuelan and grew up moving internationally before coming to Stanford for college. She is interested in neurosurgery, global health, and ethics. Natalia loves running and baking; when she’s lucky the two activities even out.

Photo of Ugandan hospital by Natalia Birgisson

CDC, Events, Global Health, Stanford News, Videos

Video of Stanford Ebola panel now available

Video of Stanford Ebola panel now available

Last week, a group of Stanford and CDC experts came together to address the health, governance, security and ethical dimensions of Ebola, the virus that is spreading rapidly in West Africa. Video of the lengthy and timely talk, courtesy of the Freeman Spogli Institute, is now available.

Previously: Ebola panel says 1.4 million cases possible, building trust key to containmentInterdisciplinary campus panel to examine Ebola outbreak from all angles, Expert panel discusses challenges of controlling Ebola in West Africa, Should we worry? Stanford’s global health chief weighs in on Ebola and Biosecurity experts discuss Ebola and related public health concerns and policy implications

Cancer, Global Health, Health Policy, Infectious Disease, Public Health

Treating an infection to prevent a cancer: H. pylori and stomach cancer

Treating an infection to prevent a cancer: H. pylori and stomach cancer

Hpylori-pic-thumb-460x385-2092

The number of newly diagnosed stomach cancer cases in the United States is less than a tenth of the number of prostate cancer cases or breast cancer cases, which may be part of the reason it doesn’t get the same attention as breast and prostate cancer. But the mortality rate is much higher for stomach (or gastric) cancer. Nearly 11,000 Americans will likely die from gastric cancer this year, with only 28 percent of cases surviving five years or more. For comparison, the five-year survival rate for prostate cancer is nearly 99 percent and for breast cancer, it’s more than 89 percent.

On a global scale, an estimated 700,000 people will die from gastric cancer this year, as Stanford infectious disease specialist Julie Parsonnet, MD, and her co-authors note in a Viewpoint piece in the most recent issue of the Journal of the American Medical Association. The authors also point out that worldwide, about 77 percent of gastric cancer cases are linked to chronic infections of Helicobacter pylori, a helix-shaped bacteria that was identified in the early 1980s and found to be linked to gastric ulcers a few years later, as well as to gastritis, an inflammation of the stomach lining that is a precursor to stomach cancer.

Researchers are still trying to understand exactly how H. pylori causes cancer or even how it colonizes the gastrointestinal track – they believe it’s picked up via food or water. Until recently, there was a dearth of randomized clinical trials that looked at the effectiveness of screening and treatment for H. pylori as a method for preventing stomach cancer.

Ignoring gastric cancer in the hope that it will soon disappear is not a tenable health policy

In the opinion piece, the authors describe the recommendations of a working group that met in December 2013 at the behest of the International Agency for Research on Cancer. Taking the burden of the disease and the availability of treatment options in consideration, the group considered gastric cancer “a logical target for intervention,” according to the authors of the JAMA piece. They go on to write:

Screening and treatment for H pylori is generally acceptable and affordable. An inexpensive serological test can determine who may be infected, with a sensitivity and specificity that could be sufficient for population-based prevention programs. Low-cost treatment regimens using 2 or 3 generic antibiotics plus a proton pump inhibitor for 7 to 14 days can eradicate the infection in more than 80% of cases, depending on the antibiotic resistance patterns of H pylori within the population. Economic modeling studies indicate that H pylori screening and treatment strategies are cost-effective under a large range of assumptions about effectiveness and costs. However, the models are limited by reliance on observational data rather than randomized trial results, by a lack of information on possible adverse effects of treatment, and by limited data from lower-income countries.

Researchers still have many gaps in their understanding of the best methods to prevent stomach cancer, but several trials may answer some of those questions in the coming decade.

Stomach cancer is not the only cancer known to be linked with an infection. Doctors routinely test whether women who come in for a PAP smear are infected with the human papilloma virus (HPV), which is linked to cervical cancer. Chronic hepatitis B and C infections are known to be linked to liver cancer. In time, screening for H. pylori to prevent stomach cancer may become routine. Until then, Parsonnet and her coauthors say in their conclusion, “Ignoring gastric cancer in the hope that it will soon disappear is not a tenable health policy.”

Previously: Researchers identify potential drug target in ulcer bug that infects half the world’s population, Good-bye cancer, good-bye stomach: A survivor shares her tale and Image of the Week: Helicobacter pylori colonizing the stomach
Photo by Shuman Tan and Lydia-Marie Joubert

CDC, Events, Global Health, In the News, Infectious Disease

Ebola panel says 1.4 million cases possible, building trust key to containment

Ebola panel says 1.4 million cases possible, building trust key to containment

ebola workers2The Ebola epidemic is spreading rapidly – leaving a wake of suffering – in large part because West Africa has shockingly few medical facilities or trained personnel. But it’s exploding exponentially because of mistrust, a panel of experts told a packed crowd on the Stanford campus last evening.

The numbers, as described by Ruthann Richter in a just-published story, are sobering:

Officially, more than 5,800 Ebola cases and 2,800 deaths from the disease have been reported in four countries: Liberia, Guinea, Sierra Leone and Nigeria. But panelists said those figures were vastly underestimated. At the current rate of spread, in which the number of new infections is doubling every three weeks, the U.S. Centers for Disease Control and Prevention estimates that 1.4 million people could be infected by the end of January 2015 in the absence of dramatic interventions, said Douglas Owens, MD, a professor of medicine and director of the Center for Health Policy at Freeman Spogli Institute of International Studies.

But even with “very aggressive” intervention, Owens said, it’s estimated there would be at least 25,000 cases by late December. If intervention is delayed by just one month, there will be 3,000 new cases every day; if it’s delayed by two months, there will be 10,000 new cases daily, he said. “It gives you a sense of the extraordinary urgency in terms of time,” Owens told the audience.

During the talk Stanford health-policy expert Paul Wise, MD, screened a CNN video that depicts a man escaping from a treatment facility in Liberia. “You have to create treatment centers that are of the highest quality and that treat people with dignity — so people will want to go there, rather than escape,” he said.

Building trust starts local, Tara Perti, MD, told the audience. She works as a CDC epidemic intelligence service officer and spent time in both Guinea and Sierra Leone this summer:

In Guinea, she traveled to a village north of the capital city of Conakry, where she met two young men who had recovered from the disease, which has a fatality rate as high as 70 percent. One of the men had lost five members of his family, but he had become a community advocate. He traveled with Perti to a neighboring village, where they met a woman who was sick and whose son had died of the disease. “She was very fearful of going to the treatment center… but she was ultimately convinced to seek treatment. She recovered and was able to return home,” Perti said.

“The patient who survived was tremendously helpful because he could speak from experience and be credible. There needs to be more of these. In the forested region of Guinea, there are a lot of superstitions and different beliefs besides germ theory, and so it’s very challenging to go into those areas and help people understand that Ebola is a virus, it’s real and we do have ways to help patients.”

The world’s disjointed response to the epidemic points points to the need for global-health reforms, Michele Barry, MD, director of Stanford’s Center for Innovation in Global Health, concluded.

Becky Bach is a former park ranger and newspaper reporter who now writes about science as an intern at the Office of Communications and Public Affairs. 

Previously: Interdisciplinary campus panel to examine Ebola outbreak from all angles, Expert panel discusses challenges of controlling Ebola in West Africa, Should we worry? Stanford’s global health chief weighs in on Ebola and Biosecurity experts discuss Ebola and related public health concerns and policy implications
Photo, of health workers at an Ebola treatment unit in Liberia, by USAID/Morgana Wingard

Events, Global Health, Health Policy, In the News, Infectious Disease, Public Health

Interdisciplinary campus panel to examine Ebola outbreak from all angles

Interdisciplinary campus panel to examine Ebola outbreak from all angles

Ebola_091914

Scientists have estimated that the West Africa Ebola epidemic will take another 12-18 months to control and will infect hundreds of thousands of more people during that time. In an opinion piece published last week in the Los Angeles Times, Michele Barry, MD, director of Stanford’s Center for Innovation in Global Health, discussed how the outbreak got so out of control and explains why the “world needs a new approach to solving massive international health crises and preventing future ones.”

Tomorrow on the Stanford campus, Barry will participate in an interdisciplinary forum focusing on the health, governance, security and ethical dimensions of the epidemic. Additional speakers include Doug Owens, MD, a general internist and director of the Center for Health Policy/Primary Care Outcomes Research; microbiologist David Relman, MD, a fellow at the Center for International Security and Cooperation; Stephen Stedman, deputy director at the Center on Democracy, Development and the Rule of Law; and Paul Wise, MD, MPH, a child health specialist and core faculty member of the Center for Health Policy/Primary Care Outcomes Research. Drawing on their diverse backgrounds, the panelists will offer unique perspectives from their respective fields on the latest developments in addressing the outbreak.

The event will be held at 4 PM local time at the Bechtel Conference Center in Encina Hall and is free and open to the public. Conference organizers will also be live tweeting the panel; you can follow the coverage on the @FSIStanford Twitter feed, or by using the hashtag #EbolaForum.

Previously: Expert panel discusses challenges of controlling Ebola in West AfricaShould we worry? Stanford’s global health chief weighs in on Ebola, Biosecurity experts discuss Ebola and related public health concerns and policy implications and Stanford global health chief launches campaign to help contain Ebola outbreak in Liberia
Photo by European Commission DG ECHO

Global Health, In the News, Infectious Disease, Public Health

Expert panel discusses challenges of controlling Ebola in West Africa

The rapidly growing Ebola outbreak in West Africa is not only overwhelming the health systems of the countries involved, but the World Bank recently warned that it could trash the economies of Liberia, Guinea, and Sierra Leone – the countries that have seen the most cases. Since the first confirmed case in December 2013 in Guinea, almost 5,000 people have become infected with the virus in five countries and about half of them have died. On September 16, President Obama committed 3,000 military personnel to help fight the outbreak, along with other resources.

This morning, KQED’s Forum hosted a panel of Ebola experts, including Michele Barry, MD, director of Stanford’s Center for Innovation in Global Health. The panel discussed some of the challenges this outbreak poses. One issue is the enormous need for resources to control an outbreak of this momentum and magnitude. The WHO estimates it will take about a billion dollars to contain and by some estimates, it will require 1,000 international health care workers to train national, local clinicians.

Barry discussed the prospects for Zmapp, an experimental drug to treat Ebola -“a cocktail of monoclonal antibodies” according to Barry – for helping to curb the disease. She said that besides the lack of human clinical data on the effectiveness of this drug, the difficulty producing the drug also slows down plans to use the medication in the field. She went on to say:

I do have optimism for containing the virus. What I don’t have optimism for is the long-term trajectory of the Liberian healthcare workforce. It’s been actually decimated. I think there are wonderful people there working on it on the ground, but actually, there’s only a only a couple hundred doctors and a serious percentage of them have died—as well as nurses, in this battle against Ebola.

She elaborated on her concerns for the long-term problems for controlling epidemics in general:

I think there are short-term problems, but then I would urge people to start – and I know many people are – to think about long term issues. The long term issues of when you have a WHO that’s had its budget decimated, and its pandemic and epidemic division disbanded. That needs to be strengthened. When you have a workforce in Africa of only – I mean they have 25 percent of the disease burden but only four percent of the workforce. That needs to be strengthened. So there are long term issues of control for future epidemics.

She also suggested that a global health worker reserve corps could be assembled, a fund to strengthen health systems could be established, much like The Global Fund to fight AIDS, Tuberculosis and Malaria, and the UN could take a more active role in large infectious disease epidemics.

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Applied Biotechnology, Bioengineering, Global Health, In the News, Stanford News

Stanford bioengineer among Popular Science magazine’s “Brilliant 10”

Stanford bioengineer among Popular Science magazine’s “Brilliant 10”

prakash-popsci

Manu Prakash, PhD, a prolific inventor of low-cost scientific tools, has been named one of Popular Science magazine’s “Brilliant 10” for 2014 – an award that recognizes the nation’s brightest young minds in science and engineering.

In the last year Prakash has introduced two novel science tools made from everyday materials.

The first was a fully functional paper microscope, which costs less than a dollar in materials, that can be used for diagnosing blood-borne diseases such as malaria, African sleeping sickness and Chagas. It can also be used by children — our future scientists — to explore and learn from the microscopic world.

The second was a $5 programmable kid’s chemistry set, inspired by hand-crank music boxes. Like a music box, users crank a wheel that feeds a strip of hole-punched paper through the mechanism. When a pin hits a hole, it activates a pump that releases a precise, time-sequenced drop of a liquid onto a surface. This low-cost device can be used to test water quality, to provide affordable medical diagnostic tests, or to design chemistry experiments in schools.

The inventions are brilliant in both their elegant simplicity and their use of emerging technologies, such as 3D printers, microfluidics, laser cutters and conductive-ink printing.

“In one part of our lab we’ve been focusing on frugal science and democratizing scientific tools to get them out to people around the world who will use them,” Prakash told Amy Adams in a recent Stanford News story. “I’d started thinking about this connection between science education and global health. The things that you make for kids to explore science are also exactly the kind of things that you need in the field because they need to be robust and they need to be highly versatile.”

Sometimes, just for the fun of it, I’ll wander over to the Prakash lab to check out the team’s new inventions. They never fail to impress.

I heartily agree with the Popular Science editors on this year’s choices for the Brilliant 10: “Remember their names: they are already changing the world as we know it.”

Previously: Manu Prakash on how growing up in India influenced his interests as a Maker and entrepreneur, Dr. Prakash goes to Washington, The pied piper of cool science tools, Music box inspires a chemistry set for kids and scientists in developing countries and Free DIY microscope kits to citizen scientists with inspiring project ideas
Illustration courtesy of Popular Science magazine

Global Health, Public Health, Stanford News

Should we worry? Stanford’s global health chief weighs in on Ebola

Should we worry? Stanford's global health chief weighs in on Ebola

13717624625_c584569b9b_kAs Ebola rampages across western Africa, Stanford Magazine sat down with Michele Barry, MD, who directs Stanford’s Center for Innovation in Global Health. Barry knows Ebola well: she’s fought it when it appeared in Uganda several years ago.

In the interview, which is posted on Medium as part of an experiment with digital communications methods, Barry shared her surprise at the momentum of the epidemic. The disease has caused more than 2,200 deaths during the past nine months in West Africa and the Democratic Republic of Congo has seen cases of a separate strain double in past week. “I think this goes back to just a very fragmented health infrastructure in the West African countries affected, a lack of personal preventive equipment on the ground and the inability to quickly educate a population that is not health literate,” she said.

Should we be worried of the epidemic spreading stateside? She responds:

I think Ebola easily could be transported here by airplane by an infected patient. The Nigeria outbreak is a result of air transport of an infected individual. But I think we have the facilities to support such patients safely. We have personal protective equipment, easily mobilized mechanisms for decontamination and isolation. I think there is no reason to be worried about it spreading in the U.S.

Barry also recently launched a fundraising campaign to care for sickened healthcare workers. Many doctors and nurses are among the thousands of Ebola casualties, including her colleague who mentored residents in the Yale/Stanford Johnson & Johnson Scholars Program.

Later this month, the Center for Global Innovation in Global Health is hosting a panel discussion that will explore the Ebola outbreak from a multidisciplinary approach. The event will be held on Sept. 23 from 4 to 5:30 p.m. at the Bechtel Conference Center on campus.  Panelists include Barry: Doug Owens, MD, director of the Center for Health Policy in the Freeman Spogli Institute for International Studies; Stanford microbiologist David Relman, MD; Stephen Stedman, PhD, Senior Fellow at the Freeman Spogli Institute for International Studies, and Paul Wise, MD, MPH, a professor of pediatrics at Stanford.

Previously: Biosecurity experts discuss Ebola and related public health concerns and policy implications, Stanford global health chief launches campaign to contain Ebola outbreak in Liberia
Photo by: European Commission

Global Health, Infectious Disease, Public Health, Public Safety, Stanford News

Biosecurity experts discuss Ebola and related public health concerns and policy implications

Biosecurity experts discuss Ebola and related public health concerns and policy implications

ebola_081214

More than 1,800 people in the West African nations of Liberia, Sierra Leone and Guinea have contracted the Ebola virus since March and the death toll has surpassed 1,000, according to the latest figures from the World Health Organization. As the number of cases and death continue to climb many are concerned about what can be done to curtail the outbreak and the likelihood of it spreading to the United States.

In a Q&A recently published by the Center for International Security and Cooperation and The Freeman Spogli Institute for International Studies, Stanford biosecurity experts David Relman, MD, and Megan Palmer jointly answer these questions and others related to the public health concerns and policy implications of the outbreak. On the topic of broader lessons about the dynamics and ecology of emerging infectious diseases that can help prevent or respond to outbreaks now and in the future, they respond:

These latest outbreaks remind us that potential pathogens are circulating, replicating and evolving in the environment all the time, and human action can have an immense impact on the emergence and spread of infectious disease.

We are starting to see common factors that may be contributing to the frequency and severity of outbreaks. Increasing human intrusion into zoonotic disease reservoir habitats and natural ecosystems, increasing imbalance and instability at the human-animal-vector interface, and more human population displacement all are likely to increase the chance of outbreaks like Ebola.

The epicenter of this latest outbreak was Guéckédou, a village near the Guinean Forest Region. The forest there has been routinely exploited, logged, and neglected over the years, leading to an abysmal ecological status quo. This, in combination with the influx of refugees from conflicts in Guinea, Liberia, Sierra Leone, and Cote d’Ivoire, has compounded the ecological issues in the area, potentially facilitating the spread of Ebola. There seems to be a strong relationship between ecological health and the spread of disease, and this latest outbreak is no exception.

While forensic analyses are ongoing, unregulated food and animal trade in general is also a key factor in the spread of infectious diseases across large geographic regions. Some studies suggest that trade of primates, including great apes, and other animals such as bats, may be responsible for transit of this Ebola strain from Central to Western Africa.

Overall, Relman and Palmer remind the public, “It’s important that we not lose sight of more chronic, but less headline-grabbing diseases that will be pervasive, insidious long-standing challenges for Africa and elsewhere.”

Previously: Stanford global health chief launches campaign to help contain Ebola outbreak in Liberia and Health workers use crowdsourced maps to respond to Ebola outbreak in Guinea
Photo by European Commission DG ECHO

From August 11-25, Scope will be on a limited publishing schedule. During that time, you may also notice a delay in comment moderation. We’ll return to our regular schedule on August 25.

Global Health, Infectious Disease, Stanford News

Stanford global health chief launches campaign to help contain Ebola outbreak in Liberia

Stanford global health chief launches campaign to help contain Ebola outbreak in Liberia

A Medical Officer at Lacor hospital in Gulu, 360 kilometers (224 miles) north of the Ugandan capital, Kampala examines a child suspected of being infected with the Ebola virus Tuesday, Oct.17, 2000. Only days after it was announced that an outbreak of Ebola, the world's most feared virus, had struck in northern Uganda the death toll rose to 35 and according to health officials 38 other people have been affected by the virus. (AP Photo/Sayyid Azim)Michele Barry, MD, director of Stanford’s Center for Innovation in Global Health, has launched a fundraising campaign to help combat the Ebola outbreak in Liberia, which has claimed the life of a colleague who mentored residents in the Yale/Stanford Johnson & Johnson Scholars Program.

Samuel Brisbane, MD, was the first Liberian doctor to die in the outbreak, which the World Health Organization says is responsible for more than 700 deaths in West Africa and is by far the largest outbreak in the history of the disease. Brisbane was an internist who treated patients at the John F. Kennedy Memorial Hospital in the capital city of Monrovia, the country’s largest hospital. A second medical officer has become ill at the hospital, one of the sites for the scholars’ program, Barry told me.

Through the program, Brisbane mentored physicians from Stanford and other institutions who volunteer for six-week stints in resource-limited countries. He quarantined himself after showing signs of illness but died on July 26 after being transferred to a treatment center, Barry said.

Like HIV, the Ebola virus is spread through direct contact with blood or body fluids from an infected individual. Barry said Liberia is in desperate need of personal protective equipment for health care workers, such as masks, gowns and gloves, as well as trained personnel who can do contact tracing and isolation of infected individuals. The Ebola virus has a 21-day incubation period, during which time an infected individual can transmit the virus.

Barry joined an informal fundraising campaign with her colleagues on Tuesday to help Liberian health-care workers contain the spread of the disease, raising $11,000 in 48 hours. Today, she broadened the appeal in an e-mail sent to all Stanford medical school faculty.

Barry has had experience fighting Ebola in Uganda, where she said outbreaks have been limited by isolating patients in outdoor, tented hospitals and where physicians and nurses have had access to good protective gear. In the past, she said the disease typically has had “hot spots” that last a month and then subside.

But the latest epidemic, which has affected patients in Guinea, Sierra Leone and Nigeria, as well as Liberia, has followed a somewhat different path.

“I think we are doing a better job of taking care of patients and keeping them alive longer, so they become more viremic — meaning the virus has spread through their bloodstream — and more infectious,” she said. “And with globalization, there is more traffic across borders so spillover to other countries occurs.”

She said she does not see the disease as a major threat to the United States, where effective infection control methods are widespread.

“I think we need to be vigilant, but I don’t think there needs to be any true concern that this is going to spread to the United States,” she said. “There’s always a risk of a patient coming in unknown to the hospital, but we practice good universal precautions because we have the equipment and we’ve been trained to treat HIV.”

Donations to the health-care project can be made online here.

Photo, from 2000 outbreak in Uganda, by ASSOCIATED PRESS

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